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1、脑卒中中西医结合诊断与治疗The burden of StrokeThe burden of StrokenA common conditionn3rd cause of death worldwide1 (after MI and cancer) Accounts for 12% of deaths n2nd cause of death within the next 10 years in developing countriesn2nd cause of dementian1st cause of severe disability the western world A major
2、health problemA major health problem中风概念nStroke; 卒中; n中风 - 缺血性中风（ischemic stroke） 出血性中风(hemorrhagic stroke) n小中风(mini-stroke); TIA n脑卒中（中风）即“脑血管意外”，指因脑血管阻塞或破裂引起的脑血 流循环障碍和脑组织功能或结构损害的疾病。可以分为缺血性脑卒中 （中风）和出血性脑卒中（中风）两大类。n缺血性脑卒中（中风），“脑梗死”，主要包括脑血栓形成和脑栓 塞两种。脑血栓形成是由于动脉狭窄，管腔内逐渐形成血栓而最终阻 塞动脉所致；脑栓塞是由于血栓脱落或其它栓子进入血
3、流中阻塞脑动 脉所引起。n出血性脑卒中（中风）根据出血部位的不同分为脑出血和蛛网膜下腔 出血。是由于脑内动脉破裂，血液溢出到脑组织内；蛛网膜下腔出血 是脑表面或脑底部的血管破裂，血液直接进入容有脑脊液的蛛网膜下 腔和脑池中。n不论是缺血性脑卒中（中风）还是出血性脑卒中（中风），都会造成 不同范围、不同程度的脑组织损害，因而产生多种多样的神经精神症 状，严重的还会危及生命，治愈后很多病人留有后遗症。-摘自雅虎知识堂 NINDS Stroke Information PageWhat is Stroke?nA stroke occurs when the blood supply to part
4、of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells. Brain cells die when they no longer receive oxygen and nutrients from the blood or there is sudden bleeding into or around the brain. nThe symptoms of a stroke inc
5、lude sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache with no known cause. Th
6、ere are two forms of stroke: ischemic - blockage of a blood vessel supplying the brain, and hemorrhagic - bleeding into or around the brain. What is Transient Ischemic Attack? Synonym(s): Mini-StrokesnA transient ischemic attack (TIA) is a transient stroke that lasts only a few minutes. It occurs wh
7、en the blood supply to part of the brain is briefly interrupted. TIA symptoms, which usually occur suddenly, are similar to those of stroke but do not last as long. Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours. nSymptoms can include: numbness or weakn
8、ess in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of balance and coordination. Definition and Evaluation of Transient Ischemic Attack A Scie
9、ntific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the InterdisciplinaryCouncil on
10、 Peripheral Vascular Disease2009TIA新概念 ndefinition of transient ischemic attack (TIA): a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. ( 脑、脊髓或视网膜局灶性缺血引 起的、未伴发急性梗死的短暂性神经功能障碍。 ) nPatients with TIAs are at high risk of e
11、arly stroke, and their risk may be stratified by clinical scale, vessel imaging, and diffusion magnetic resonance imaging. Diagnostic recommendations include: TIA patients should undergo neuroimaging evaluation within 24hours of symptom onset, preferably with magnetic resonance imaging, including di
12、ffusion sequences; noninvasive imaging of the cervical vessels should be performed and noninvasive imaging of intracranial vessels is reasonable; electrocardiography should occur as soon as possible after TIA and prolonged cardiac monitoring and echocardiography are reasonable in patients in whom th
13、e vascular etiology is not yet identified; routine blood tests are reasonable; and it is reasonable to hospitalize patients with TIA if they present within 72 hours and have an ABCD2 score _3, indicating high risk of early recurrence, or the evaluation cannot be rapidly completed on an outpatient ba
14、sis. (Stroke. 2009;40:2276-2293.) n金匮要略：提出中风病名。在经在 络、中脏中腑区别。n卒中-素问本病论日：“久而化郁 ，即大风摧拉，折损鸣乱。民病卒中偏 痹，手足不仁。n明 楼英医学纲目 卷之十肝胆部 首提卒中病名。现代中风病概念n中风病是在气血内虚的基础上，因劳倦内伤、 忧思恼怒、嗜食厚味及烟酒等诱因，引起脏腑 阴阳失调，气血逆乱，直冲犯脑，导致脑脉痹 阻或血溢脑脉之外，临床以突然昏仆、半身不 遂、口舌歪斜、言语謇涩或不语、偏身麻木为 主症，具有起病急、变化快的特点，好发于中 老年人的一种常见病。n相当于脑卒中，从病理上分为缺血性中风和出 血性中风。缺血性
15、中风和出血性中风？n出血性中风和缺血性中风的病因病机，现代医学传 入我国之前，中医并无区分，即古代中医对中风并 未认识到象现今所分脑络瘀阻和血瘀脉外之不同。 因而两种不同的中风的中医治疗并无差异。n晚清时期，伴随现代医学的传入，中医逐渐接受了 西医的观点，其中晚清张山雷、张锡纯为主要代表 ，张锡纯医学衷中参西录脑贫血证和脑充血证 即大体相当缺血性脑血管病和出血性脑血管病。自 此脑出血治疗认识上始有不同。诊断与鉴别诊断诊断与鉴别诊断1.疾病诊断n（1）临床表现：神识昏蒙、半身不遂、口舌歪斜、言 语謇涩或不语、偏身麻木；或出现头痛、眩晕、瞳神变 化、饮水发呛、目偏不瞬、共济失调等。n（2）急性起病
16、，渐进加重，或骤然起病，即刻达到高 峰。n（3）发病前多有诱因，常有先兆症状。n（4）发病年龄多在40岁以上。n具备以上临床表现，结合起病形式、诱因、先兆症状、 年龄即可诊断；影像学检查（CT或MRI）可助明确诊断 。2.病类诊断n（1）中经络：中风病而无神 识昏蒙者。n（2）中脏腑：中风病而有神识昏蒙者。3.分期标准？n急性期：发病4周以内n恢复期: 发病半年以内n后遗症期: 发病半年以上中国分期中西医一致脑卒中的临床分期英国皇家医学会指南80岁有选择性的 患者仍可静脉应用rtPA(III类证据，C级建议)。n6h时间窗内的急性大脑中动脉闭塞患者，动脉内治疗可作为一个治疗选项 (II类证据，B级建议)。n符合筛选标准的急性基底动脉闭塞患者，可应用动脉内溶栓治疗(III类证 据，B级建议)。即使超过3小时，仍可应用静脉溶栓治疗(III类证据，B级 建议)。n建议缺血性卒中发病后48小时内给予阿司匹林(160325
